NRSG378 – Principles of Nursing Extended Clinical Reasoning Case Study Example

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NRSG378 – Principles of Nursing Extended Clinical Reasoning Case Study Example

NRSG378 - Principles of Nursing Extended Clinical Reasoning Case Study ExampleNRSG378 – Principles of Nursing Extended Clinical Reasoning Case Study Assignment

NRSG378 – Principles of Nursing: Extended Clinical Reasoning Assessment Task 3 – Case Study

NRSG378 – Principles of Nursing Extended Clinical Reasoning Case Study Assignment Brief

Assignment Instructions Overview:

This case study assignment requires students to apply unit learnings to assess, prioritize, and plan nursing care for an acutely unwell patient using a structured clinical reasoning framework. Students must critically link theoretical knowledge to the patient’s presentation and management within the acute care setting.

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Understanding Assignment Objectives:

The objective of this task is to strengthen clinical reasoning skills through the analysis of an acute clinical situation. Students must demonstrate the ability to understand the pathophysiology of illness, recognize clinical cues, identify nursing and patient problems, plan evidence-based interventions, and consider the holistic impact of illness on patient well-being.

The Student’s Role:

Students are expected to step into the role of a registered nurse managing an acutely ill patient. They must assess clinical information, make informed nursing judgments, prioritize care needs, and formulate a detailed care plan using a systematic clinical reasoning approach. Students should integrate theoretical concepts with practical nursing care strategies while addressing both physical and psychosocial patient needs.

Competencies Measured:

This assignment evaluates competencies in critical thinking, clinical decision-making, pathophysiological knowledge, nursing assessment, prioritization of care, pharmacological understanding, evidence-based intervention planning, and holistic patient care. It also measures the ability to apply a clinical reasoning framework systematically to patient management.

NRSG378 – Principles of Nursing Extended Clinical Reasoning Case Study Example

Extended Clinical Reasoning Case Study: Care of Kate Sansbury

  1. Disease Pathophysiology and Patient Assessment

Kate Sansbury, a 22-year-old female, presented to the emergency department with worsening abdominal pain, nausea, vomiting, and general malaise. Initially experiencing dull pain localized to the right lower quadrant, her symptoms progressed over three days to severe, sharp pain that triggered vomiting and restricted oral intake. Clinical assessment revealed tachycardia (HR 118 bpm), hypotension (BP 90/60 mmHg), fever (39.2°C), mild work of breathing (RR 24 bpm), and physical signs of dehydration and guarding.

These symptoms strongly suggest perforated appendicitis leading to secondary peritonitis. Appendicitis occurs when the lumen of the appendix becomes obstructed, often by lymphoid hyperplasia, fecaliths, or foreign bodies (Stringer, 2017). This blockage promotes bacterial overgrowth, increased intraluminal pressure, vascular compromise, and eventually, necrosis. In untreated cases, the appendix can rupture, spilling infectious material into the peritoneal cavity, leading to secondary peritonitis, a serious and potentially life-threatening condition (Clements et al., 2021).

Kate’s elevated white blood cell count (15 x 10⁹/L) and C-reactive protein (150 mg/L) indicate a strong systemic inflammatory response. Her elevated lactate (2.0 mmol/L) suggests early tissue hypoperfusion. The presence of minimal bowel sounds, guarding, and a distended abdomen point to peritonitis, which results from widespread inflammation of the peritoneum. Inflammation leads to third-spacing of fluids into the peritoneal cavity, contributing to intravascular volume depletion, reflected in Kate’s hypotension and signs of dehydration.

Elements of a comprehensive nursing assessment for Kate include:

  • Full set of vital signs monitoring (hourly)
  • Detailed pain assessment (scale, location, radiation, characteristics)
  • Fluid balance charting (input/output monitoring)
  • Abdominal assessment (inspection, auscultation, palpation, percussion)
  • Neurological status monitoring (GCS assessment)
  • Skin turgor, mucous membranes hydration status
  • Electrolyte and renal function monitoring
  • Respiratory assessment
  • Psychosocial evaluation (stress levels, mental health status)
  • Nutritional assessment
  • Mobility assessment
  1. Nursing and Patient Issues

Three primary nursing issues emerge from Kate’s case: pain management, infection control, and fluid volume deficit management.

2.1 Pain Management

Pain presents as a dominant issue for Kate, rated 8/10 and limiting her movement. Uncontrolled pain can lead to numerous adverse outcomes, including heightened stress responses, impaired respiratory function, delayed mobilization, and prolonged recovery (Jiang, 2019). Severe pain also exacerbates sympathetic nervous system activation, potentially worsening her hemodynamic instability. Effective pain management will optimize Kate’s comfort, enhance cooperation with care procedures, and promote faster postoperative recovery.

2.2 Infection Control

The perforated appendix has allowed bacterial contamination of the peritoneal cavity, triggering secondary peritonitis. Infection control becomes crucial to prevent progression to sepsis, a life-threatening condition associated with significant morbidity and mortality (Jones et al., 2021). Proactive infection management, including aseptic techniques, early antibiotic therapy, and vigilant monitoring of vital signs and inflammatory markers, is essential to stabilize Kate’s condition and prevent further complications.

2.3 Fluid Volume Deficit

Kate exhibits significant fluid loss due to vomiting, fever, and third-spacing of fluids into the peritoneal cavity. Clinical signs, including dry lips, reduced urine output, hypotension, and elevated lactate levels, all support the presence of hypovolemia. Failure to promptly address her fluid deficit may worsen tissue perfusion and precipitate septic shock (Michaelides & Zis, 2019). Aggressive fluid resuscitation with isotonic crystalloids remains essential.

Impact on Activities of Living

Nutrition and Hydration: Kate’s inability to tolerate oral intake and ongoing fluid losses compromise her nutritional status. Maintenance of adequate hydration and electrolyte balance is vital for wound healing, immune function, and overall recovery.

Mobility: Postoperative pain, abdominal tenderness, and surgical intervention will likely impair Kate’s mobility. Early mobilization post-surgery prevents complications such as deep vein thrombosis, pulmonary embolism, and promotes bowel function return (Haahr-Raunkjaer et al., 2022).

  1. Pharmacological Management

Kate’s pharmacological management focuses on antibiotics and analgesics, both vital for treating her underlying infection and managing pain.

3.1 Antibiotics (Beta-lactam class)

Broad-spectrum beta-lactam antibiotics, such as ceftriaxone, play a key role in Kate’s treatment. Beta-lactams inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins, leading to cell lysis and death (Pandey & Cascella, 2022). In cases like Kate’s, early administration of broad-spectrum antibiotics helps control peritoneal contamination and limits systemic infection progression. Nursing considerations include monitoring for signs of allergic reactions, ensuring timely administration, and reassessing therapy once culture results become available (Blumenthal et al., 2019).

3.2 Analgesics (Opioid class)

Opioids, such as morphine, provide essential pain relief for patients experiencing severe postoperative pain. Opioids act by binding to mu-receptors in the central nervous system, altering the perception and emotional response to pain (Vadivelu et al., 2018). For Kate, PRN morphine ensures rapid pain control, aiding in relaxation, reduced sympathetic activation, and smoother postoperative recovery. Nursing considerations involve regular pain assessment, close monitoring for respiratory depression, sedation, and gastrointestinal side effects such as constipation, which may complicate recovery.

Additional supportive medications include antiemetics like ondansetron to control postoperative nausea and vomiting, contributing to better comfort and hydration status.

  1. Nursing Interventions

4.1 Prioritized Nursing Interventions in the First 24 Hours Post-Surgery

4.1.1 Monitoring and Assessment

Continuous monitoring of Kate’s vital signs, fluid balance, and neurological status remains the top priority. Early detection of hypotension, tachycardia, hypoxia, or altered mental status can signal deterioration, requiring urgent intervention (Michard et al., 2020). Hourly observations of blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and pain levels ensure rapid identification of postoperative complications, including hemorrhage, sepsis, or respiratory compromise.

Rationale: Early detection enables timely interventions and prevents severe complications, including septic shock.

4.1.2 Pain Management

Effective pain management is essential to enhance Kate’s recovery. Pain must be assessed regularly using validated tools like the Numeric Rating Scale (0-10) or the Verbal Descriptor Scale. PRN opioids, in combination with non-pharmacological strategies such as repositioning, relaxation techniques, and emotional support, should be provided.

Rationale: Adequate pain control improves comfort, encourages deep breathing, promotes early ambulation, and prevents postoperative pulmonary complications (Chiarotto et al., 2019).

4.1.3 Fluid Resuscitation and Electrolyte Management

Strict input and output monitoring and ensuring the prescribed IV fluid regimen are critical. Regular electrolyte review (e.g., sodium, potassium) must guide further fluid and electrolyte replacement strategies to prevent imbalances.

Rationale: Restoration of circulatory volume enhances tissue perfusion and oxygen delivery, essential for healing and recovery (Michaelides & Zis, 2019).

4.1.4 Infection Prevention

Strict aseptic technique must be maintained during all care activities, including wound care and IV access management. Surgical wounds should be assessed at least once per shift for signs of infection, including redness, swelling, warmth, or discharge. Prophylactic antibiotic administration must follow the hospital schedule precisely.

Rationale: Meticulous infection prevention minimizes the risk of postoperative sepsis and wound dehiscence (Kim et al., 2019).

4.1.5 Early Mobilization

Kate should be encouraged to mobilize as soon as she is medically stable. Initial mobilization should occur with assistance, ensuring pain control and hemodynamic stability. Passive range-of-motion exercises should be initiated if active mobilization is delayed.

Rationale: Early mobilization prevents complications like deep vein thrombosis, pulmonary embolism, and promotes the return of gastrointestinal function (Haahr-Raunkjaer et al., 2022).

4.1.6 Respiratory Care

Incentive spirometry, deep breathing exercises, and regular repositioning should be part of Kate’s postoperative care plan to prevent atelectasis and pneumonia.

Rationale: Postoperative respiratory exercises reduce the risk of hypoventilation and respiratory infections, particularly after abdominal surgery (Ramachandran et al., 2017).

4.1.7 Psychosocial Support

Given Kate’s history of depression and current worries about missing her veterinary placement, emotional support must be incorporated into the care plan. Open, empathetic communication should be maintained, and a referral to mental health services considered if anxiety or depressive symptoms escalate.

Rationale: Addressing psychosocial needs promotes holistic recovery and reduces the risk of psychological complications (Michaelides & Zis, 2019).

References

Blumenthal, K. G., Peter, J. G., Trubiano, J. A., & Phillips, E. J. (2019). Antibiotic allergy. The Lancet, 393(10167), 183-198.

Chiarotto, A., et al. (2019). Measurement properties of pain intensity scales. British Journal of Anaesthesia, 123(2), e270-e282.

Clements, W. D., et al. (2021). Peritonitis: Clinical perspectives and management. Surgical Infections, 22(5), 407-416.

Dowling, J., et al. (2017). Infectious diseases and antibiotic management. Journal of Clinical Pharmacology, 57(6), 690-705.

Fikri, M., et al. (2023). Pathophysiology of acute appendicitis: A review. Clinical Surgery Journal, 28(2), 120-127.

Haahr-Raunkjaer, C., et al. (2022). Early mobilization strategies following surgery. European Journal of Anaesthesiology, 39(2), 149-157.

Jiang, Y. (2019). Pain management in surgical patients. International Journal of Surgery, 65, 38-43.

Jones, M. C., et al. (2021). Preventing surgical site infections. American Journal of Surgery, 221(2), 293-298.

Kim, D. J., et al. (2019). Surgical infections: Diagnosis and management. Clinical Infectious Diseases, 68(3), 414-421.

Michaelides, A., & Zis, P. (2019). Management of dehydration and electrolyte imbalance. Frontiers in Physiology, 10, 570.

Michard, F., et al. (2020). Hemodynamic monitoring in postoperative care. Critical Care, 24(1), 20.

Pandey, S., & Cascella, M. (2022). Beta-lactam Antibiotics. StatPearls Publishing.

Perez, E., & Allen, S. (2018). Diagnosis and management of appendicitis. Clinical Practice and Cases in Emergency Medicine, 2(1), 71-74.

Ramachandran, S. K., et al. (2017). Risk factors for postoperative respiratory depression. Anesthesia & Analgesia, 124(5), 1669-1675.

Salazar Maya, A. M. (2022). Best practices in postoperative nursing care. Journal of Perioperative Practice, 32(7), 214-221.

Stringer, M. D. (2017). Acute appendicitis. Journal of Paediatrics and Child Health, 53(11), 1071-1076.

Vadivelu, N., et al. (2018). Pain management post-surgery. Pain Practice, 18(5), 524-532.

Detailed Assessment Instructions for the NRSG378 – Principles of Nursing Extended Clinical Reasoning Case Study Assignment

ASSESSMENT INFORMATION
Assessment Title  

Assessment Task 3 – Case Study
Purpose This assessment enables students to apply knowledge from unit learnings to an issue requiring extended clinical reasoning.

The assessment will engage students with the application of theory to practice and is designed to facilitate an understanding of the impact of illness on the patient. It is

also intended to give students the opportunity to demonstrate the ability to use a clinical reasoning framework to plan the care of an acutely unwell patient.
Due Date Wednesday 24th May 2023
Time Due 14:00
Weighting 50%
Length 2000 words
Assessment Rubric  

Appendix 2 of the NRSG378 unit outline
LEO

Resource

 A national pre-recorded video will be uploaded onto LEO in week seven (7), which will provide students with an overview of the assessment as well as resources and advice on how to approach the task.

Students are encouraged to post questions on the discussion forum on LEO and to check for answers there as a first point of query.
LOs Assessed  

LO1, LO2, LO3, LO4
Task Students will assess, prioritise and plan the care of the case study patient using a clinical reasoning framework.

Sections you need to respond to include:

1.     Disease pathophysiology and patient assessment (500 words):

·        Provide an initial impression of the patient and identify relevant and significant features from the patient presentation;

·        Discuss in detail, the pathophysiology of the disease and how Kate’s presenting signs and symptoms reflect the underlying pathophysiology;

·        Identify further elements of a comprehensive nursing assessment (this can be presented as a list)

 

2.     Identify nursing and patient issues (500 words):

·        Identify and prioritise 3 nursing issues you must address for Kate and justify why they are priorities and support your discussion with evidence and data from the case study. These can be actual or at-risk issues.

·        Discuss the potential impact of this admission on Kate’s 2 most important activities of living (can be biological, psychosocial, spiritual or cultural factors)

 
  1. Discuss the pharmacological management (400 words):
    • Identify and discuss two (2) common classes of drugs used for Kate, including the drug mechanism of action, indication and nursing considerations. This does not mean specific drugs but rather the class that these drugs belong to.
  1. Nursing interventions (600 words):
    • Identify, rationalise and explain, in order of priority, the nursing care strategies you should use within the first 24 hours post-surgery for Kate.

Case Study          Kate Sansbury is a 22-year-old female who presented to the emergency department (ED) with abdominal pain, nausea and vomiting, and general malaise. She stated that the pain appeared 3 days ago but was dull and localised to the right lower quadrant only, and resolved when she applied a heat pack and took some paracetamol. She assumed the pain was due to her upcoming period.

Last night at 3am she woke when the abdominal pain became sharp and was so “intolerable” she vomited. She has since had 2 further vomits, and states she feels ongoing nausea. She has not been able to eat or drink her usual amounts for the past day. She states she has only voided once yesterday and it was “very dark yellow” in colour.

On assessment:

  • Kate appears pale, cool and clammy. Her lips appear dry
  • She is lying in a semi-Fowler’s position and has her hands across her stomach (guarding). Kate appears reluctant to move
  • Her abdomen is distended and tender, and there are minimal abdominal sounds on auscultation
  • On abdominal palpation, she states the pain is 8/10 on the right lower quadrant, but the pain also occurs across her abdomen, and it is becoming worse

Health assessment findings and laboratory results at presentation:

  • HR 118 bpm, regular pulse
  • BP 90/60 mmHg
  • RR 24 bpm, mild WOB
  • Temp 39.2C
  • SpO2 97% on RA
  • Alert and orientated to time, place, and person. GCS 15
  • CRT 2 seconds
  • Last bowel motion – yesterday but patient states she feels “constipated”
  • Weight – 62kg

 

Result Normal Values
Haemoglobin (Hb) 145 g/L 150-160 g/L (females)
WBC 15 x 109/L 4-11 x 109/L
Sodium 132 mmol/L 135 to 145 mmol/L
Potassium 3.5 mmol/L 3.5 to 5.2 mmol/L
Lactate 2.0 mmol/L <1.0 mmol/L
C-reactive protein (CRP) 150 mg/L <5 mg/L
Human chorionic

gonadotropin (hCG)

 < 5 IU/L Not pregnant < 5 IU/L
Blood cultures Pending Negative

 

Patient history:

Kate currently lives with two friends in a share house in an inner-city suburb in Melbourne. She works part-time as a retail worker in a bookshop, and studies veterinary nursing at TAFE full-time. She states that she is due to commence placement soon for her studies, and is “worried I won’t be able to attend and fail”.

She consumes a healthy diet, and only eats takeout once every few weeks. Kate exercises 4 days a week, for approximately 1 hour each time and considers herself “fit and healthy”. She does not smoke and has 2 standard alcohol drinks every Saturday when she goes out with her friends. She also smokes marijuana recreationally when she becomes “stressed out”.

Family history:

 

·        Parents live in Darwin and are both well with no medical concerns

·        Kate visits them once a year during Christmas

 

Medical history:

·        Depression

·        Asthma

 

Medications:

·        Sertraline 50mg daily

·        Salbutamol 4-6 puffs via pMDI PRN

 

Following the review of her laboratory tests and assessment results, Kate has been diagnosed with ?perforated appendix leading to secondary peritonitis

 

Management

 

·        Administer IV bolus NaCl 0.9% 500ml over less than 15 minutes

·        Commence IV NaCl 0.9% at 70ml/hr

·        Administer IV ceftriaxone 1g BD

·        Administer IV morphine 2mg PRN

·        Administer IV ondansetron 4mg PRN

·        1/24 vital obs and pain assessment

·        Repeat UEC 2 hours post IVF commencement

·        SFBC

·        NBM

·        Pre-op preparation for an emergency appendectomy and peritoneal cleanout

 

You are the registered nurse looking after Kate, and you are required to plan her care guided by a clinical reasoning framework and the provided case study information.
Submission Via the Turnitin dropbox in the NRSG378 LEO site under the “Assessment” tile.

 

 

FORMATTING
File format The information will be presented as a question-and-answer format. There is no need to include an introduction or conclusion.

Do not include the question in your assessment, just label it as 1), 2), etc.

Each answer has a word limit; answers beyond this limit will not be considered in your mark.

The assessment will be submitted as a Microsoft Word document file via Turnitin. Please do not submit pdf files.
 

REFRENCING
Referencing Style APA 7th edition
 

 

Minimum References

 A minimum of 15 high quality resources are to be used. All arguments must be supported using a variety of high-quality primary evidence. Avoid using any one source repetitively.
Age of References Published in the last 5 years unless using seminal text.
Alphabetical Order References are arranged alphabetically by author family name
Hanging Indent Second and subsequent lines of a reference have a hanging indent
DOI Presented as functional hyperlink
Spacing Double spacing the entire reference list, both within and between entries
 

ADMINISTRATION
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Late Penalties

 Late penalties will be applied from 2:01pm on the due date, incurring 5% penalty of the maximum marks available up to a maximum of 15%. Assessment tasks received more than three calendar days after the due or extended date will receive feedback but will not be allocated a mark.

Penalty Timeframe         Penalty Marks Deducted

2:01pm Wednesday to 2pm Thursday        5% penalty          5 marks 2:01pm Thursday to 2pm Friday   10% penalty        10 marks 2:01pm Friday to 2pm Saturday              15% penalty        15 marks Received after 2:01pm Saturday               No mark allocated

Example:

An assignment is submitted 12 hours late and is initially marked at 60 out of

100. A 5% penalty is applied (5% of 100 is 5 marks). Therefore, the student receives 55 out of 100 as a final mark.
Final Assignment Marks for this last assessment will be returned after release of final unit results.
Assessment template project informed by ACU student forums, ACU Librarians and the Academic Skills

Unit.

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